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This study adds insight regarding the occurrence and spread of SARS-CoV-2 Variants of Concern (VOCs) and Var-iants of Interest (VOIs) in Italy in October and November 2022, by testing urban wastewater collected through-out the country. A total of 332 wastewater samples were collected from 20 Italian Regions/Autonomous Provinces (APs) within the framework of national SARS-CoV-2 environmental surveillance. Of these, 164 were collected in the first week of October and 168 in the first week of November. A similar to 1600 bp fragment of the spike protein was sequenced by Sanger (for individual samples) and long-read nanopore sequencing (for pooled Region/AP samples).In October, mutations characteristic of Omicron BA.4/BA.5 were detected in the vast majority (91 %) of the samples amplified by Sanger sequencing. A fraction of these sequences (9 %) also displayed the R346T mutation. Despite the low prevalence documented in clinical cases at the time of sampling, amino acid substitutions characteristic of sublineages BQ.1 or BQ.1.1 were detected in 5 % of sequenced samples from four Regions/APs. A significantly higher variability of sequences and variants was documented in November 2022, when the rate of se-quences harbouring mutations of lineages BQ.1 and BQ1.1 increased to 43 %, and the number of Regions/APs positive for the new Omicron subvariant more than tripled (n = 13) compared to October. Moreover, an increase in the number of sequences with the mutation package BA.4/BA.5 + R346T (18 %), as well as the detection of variants never observed before in wastewater in Italy, such as BA.2.75 and XBB.1 (the latter in a Region where no clinical cases asso-ciated with this variant had ever been documented) was recorded.The results suggest that, as predicted by the ECDC, BQ.1/BQ.1.1 is rapidly becoming dominant in late 2022. Environ-mental surveillance proves to be a powerful tool for tracking the spread of SARS-CoV-2 variants/subvariants in the population.

Background myocardial work (MW) is a novel echocardiographic technique that enables the study of left ventricular performance. It overcomes speckle tracking echocardiography (STE) limitations, dependent on afterload, which is increased in patients with severe aortic stenosis (AS). Aims: To evaluate myocardial performance indexes obtained with MW in patients with AS and indication to percutaneous aortic valve replacement (TAVR) before and after the procedure. Methods patients with severe AS and preserved left ventricular systolic function (LVEF) and indication to TAVR underwent complete echocardiographic evaluation the day before and within two days after the procedure. MW indices were calculated considering noninvasive systolic blood pressure (SBP) and corrected for the mean transvalvular aortic gradient. Results 39 patients (78±6 years, 61.5% women) were enrolled, they presented at baseline preserved LVEF (59.4±8.2%) and reduced global longitudinal strain (GLS) (–16.8±3.3%). Corrected global work index (cGWI) and corrected global constructive work (cGCW) appeared elevated before the procedure, and were significantly reduced within 2 days after TAVR (cGWI –2460.5±839.7 mmHg% vs 1844.4±521.6 mmHg%, p Conclusions The reduction in cGWI and cGWC values and thus myocardial oxygen consumption in the immediate post–TAVR is attributable to the reduction in afterload. Left ventricular function abnormalities do not totally regress after the procedure, although the lack of reduction in cGWW could be partly due to the development of atrioventricular or intraventricular conduction defects. Further studies are desirable to define a role of MW in prognostic stratification of patients with severe AS.

Resume Introduction L’embolie pulmonaire (EP) est une pathologie cardiovasculaire frequente et potentiellement grave. Le traitement de l’EP repose sur une stratification appropriee du risque, pour une prise en charge adaptee. Le but de cet article est de definir la place des nouvelles methodes endovasculaires pour la prise en charge des embolies pulmonaires, sur la base d’un consensus pluridisciplinaire. Donnees recentes Brievement, pour une EP a haut risque, presentant un etat de choc ou un arret cardiaque, une thrombolyse systemique ou une embolectomie est recommandee, alors que pour une EP a faible risque, l’anticoagulation seule est proposee. Les patients normaux tendus atteints d’EP mais presentant des signes biologiques ou d’imagerie de dysfonctionnement du cœur droit constituent un groupe dit « a risque intermediaire » pour lequel la strategie therapeutique reste controversee. En effet, certains patients peuvent necessiter une prise en charge plus agressive en complement du traitement anticoagulant, car environ 10 % vont decompenser hemodynamiquement avec un risque de mortalite eleve. La thrombolyse systemique peut etre une option, mais avec des risques hemorragiques en particulier intracrâniens. Des approches pharmaco-mecaniques hybrides variees sont proposees pour conserver les avantages de la thrombolyse tout en reduisant ses risques, mais l’experience clinique globale de ces differentes techniques reste limitee. Les patients presentant une embolie pulmonaire a risque intermediaire eleve et a haut risque doivent etre pris en charge par une equipe pluridisciplinaire alliant les competences des cardiologues, reanimateurs, pneumologues, radiologues interventionnels et chirurgiens cardiaques. Une telle equipe peut determiner quelle intervention – thrombolyse seule ou assistee, fragmentation mecanique percutanee du thrombus ou embolectomie chirurgicale – convient le mieux a un patient particulier. Conclusion A partir des donnees de la litterature, il est possible de stratifier la prise en charge des embolies pulmonaires en fonction du tableau clinique et de proposer a certaines formes severes une thrombectomie endovasculaire.

Funding Acknowledgements Type of funding sources: None. Background Adults with coarctation of the aorta (CoA) may present residual aortic obstruction and develop arterial vasculopathy and subclinical left ventricular (LV) dysfunction. Myocardial work (MW) is a novel non-invasive index of myocardial efficiency calculated from echocardiographic LV pressure-strain loops, which yields incremental information over ejection fraction and global longitudinal strain. (GLS) Purpose Aim of the present study is to analyze LVMW in a cohort of adult patients with operated aortic CoA Methods CoA patients aged > 18 years who underwent transthoracic echocardiography between September 2020 and July 2021 at our tertiary centre were included. Exclusion criteria were significant recoarctation, impaired LVEF, significant valvular disease and suboptimal image quality. A group of healthy individuals with no cardiac abnormalities. GLS and peak strain dispersion(PSD) were measured. MW indices were calculated using the blood pressure measured in the right arm at the time of the exam. Results Sixty patients (26[22-33]years, 66%male) were included. Data on previous medical history, clinical status at last assessment and Coa-related echocardiographic findings are showed in table 1. No significant differences in traditional parameters of LV systolic and diastolic function were found between groups (EF 60[57-64] vs 57[53-61],p = 0.6), however Coa patients had higher LVmass (84[75-97] vs 68[56-75]g). GLS and MW indices in the study population and in the control group are reported in table 2. Coa group showed lower GLS values and higher PSD (p 0.0001). Conclusion MW indices assessment is feasible in Coa patients may provide a more comprehensive understanding of the overall myocardial mechanics and performance. In particular, MW demonstrated impaired LV efficiency, which was strongly related to increased mechanical dispersion in Coa patients. Abstract Figure. Abstract Figure.

Funding Acknowledgements Type of funding sources: None. Background myocardial work (MW) is a novel echocardiographic technique which assesses left ventricular (LV) performance through LV pressure-strain loops. MW corrects speckle tracking echocardiography (STE)-derived parameters for afterload using non-invasive systolic blood pressure (SBP) as a surrogate for LV systolic pressure. In patients with severe aortic stenosis (AS), the corrected MW (cMW) has been proposed, consisting in adding the mean aortic gradient in SBP. This method revealed to be feasible and reliable, demonstrating good correlation with invasively measured LV systolic pressure. Purpose to evaluate myocardial performance of patients with severe AS, before and after transcatheter aortic valve implantation (TAVI), by MW indices. Methods patients with severe AS undergoing TAVI were included. Transthoracic, standard echocardiography and STE were performed the day before the procedure and within 2 days after. MW was calculated by combining STE-derived indices with non-invasively estimated LV systolic pressure. Results 30 patients (79 ± 5 years old, 56% females) with severe AS (mean gradient 47 ± 14 mmHg, aortic valve area 0.6 ± 0.1 cm2), and eligible for TAVI were enrolled. Baseline global longitudinal strain was impaired (GLS -15 ± 4%), in presence of normal LV ejection fraction (LVEF 57 ± 10%). Corrected global work index and global constructive work were preserved at baseline and markedly decreased after TAVI (cGWI 2322 ± 791 vs 1710 ± 505 mmHg%, p = 0.001; cGCW 2774 ± 803 vs 2083 ± 536 mmHg%, p = 0.0007). Corrected global wasted work and global work efficiency were higher than reference values existing in literature, and no significant changes were observed after TAVI (cGWW 276 ± 174 vs 277 ± 165 mmHg%, p = 0.974; cGWE 89 ± 5 vs 87 ± 5%, p = 0.177). A significant inverse correlation was found between baseline cGWI and left atrial volume index (r=-0.5, p = 0.03). Conclusions patients with severe aortic stenosis and preserved LVEF show a good LV performance before and after TAVI, with a significant decrease in MW indices after TAVI, because of the reduced afterload due to AS treatment. The negative correlation between left atrial volume and cGWI may reflect the extent of myocardial damage in AS. However, further studies with larger sample size and appropriate follow-up are needed to evaluate the role of MW in prognosis and risk stratification of this subset of patients.

Background Adults with congenital heart disease (ACHD) are frequently affected by thyroid diseases (TD). However, the clinical relevance of TD in ACHD remains unknown. Purpose We aimed to describe the prevalence of TD in the ACHD population and to ascertain whether TD are associated with worse outcome. Methods Clinical data on all consecutive patients aged >18 years attending our ACHD unit for a day-case between 2014 and 2019 were retrospectively collected. For statistical analysis, a composite endpoint was created combining the following events at follow-up: hospitalization for heart failure, new-onset tachyarrhythmic or bradyarrhythmic events and death. Results Four hundred ninety-five ACHD patients with a median age of 32.2 [24.5–45.6] years (46% male) were included. There was an overall prevalence of patients with moderate or complex lesions (414=84%). Compared to the group with no history of TD, patients in the TD were older, (41.9 [29.7–53.5] vs 30.2 [24.3–39] years; p Median follow-up was 9.4 [4.5–13.1] years. Patients with TD had a higher unadjusted mortality rate, with a trend towards statistical significance (p=0.07). Sixty-four (42%) patients in the TD group and 43 (12.5%) met our composite endpoint, leading to a 10-year survival free from events of 53.7% Vs 86.5%, respectively (p Conclusion TD is a strong predictor of adverse outcome in the ACHD population after exclusion of potential confounding factors, being related to a fourfold increased risk of events at follow-up. Funding Acknowledgement Type of funding sources: None. Figure 1Table 1

Purpose The purpose of this study was to report the clinical evaluation of a 3D-printed protective face shield designed to protect interventional radiologists from droplet transmission of the SARS-Cov-2. Materials and methods A protective face shield consisting in a standard transparent polymerizing vinyl chloride (PVC) sheet was built using commercially available 3D printers. The 3D-printed face shield was evaluated in 31 interventional procedures in terms of ability to perform the assigned intervention as usual, quality of visual comfort and tolerance using a Likert scale (from 1, as very good to 5, as extremely poor). Results The mean rating for ability to perform the assigned intervention as usual was 1.7 ± 0.8 (SD) (range: 1–4). The mean visual tolerance rating was 1.6 ± 0.7 (SD) (range: 1–4). The mean tolerability rating was 1.4 ± 0.7 (SD) (range: 1–3). Conclusion The 3D-printed protective face shield is well accepted in various interventions. It may become an additional option for protection of interventional radiologists.

International audience; No abstract available

Purpose The purpose of this study was to assess the relationship between the number of microcatheters required for prostatic artery embolization (PAE) and the anatomy of the prostatic artery (PA). Materials and methods All consecutive patients who underwent PAE between May 2017 and December 2018 were included. The anatomical description of the PAs was assessed by both global cone beam computed tomography and selective angiography and data on the resources used, in terms of microcatheters, were prospectively collected. Results A total of 215 consecutive patients (mean age, 66 ± 8.7 [SD] years; range: 45–93 years), with a mean International Prostate Symptom Score of 21 ± 7.4 (SD) and a mean prostate volume on magnetic resonance imaging of 88 ± 38 (SD) mL (range: 30–200 mL) underwent PAE. A single PA was observed in 347 hemipelvises (347/411; 84.4%) and double PAs in 64 (64/411; 15.6%). Eighty percent (173/215 patients) of PAEs were performed using a single microcatheter. Type I PA anatomy required significantly more microcatheters (1.15 ± 0.39 [SD]; range: 1–3), than type II (1.04 ± 0.19 [SD]; range: 1–2), type III (1.09 ± 0.34 [SD]; range: 1–3) and type IV (1.06 ± 0.27 [SD]; range: 1–2) (P = 0.01 for all). Conclusion PAE is feasible with limited per-intervention changes in devices for all types of PA anatomy encountered. This could help in the design of appropriate reimbursement policies in various healthcare settings.

To prospectively evaluate the feasibility and reproducibility of the semiquantitative measurement of the unenhanced area of the prostate by trans-abdominal contrast-enhanced ultrasound (CEUS) performed immediately after prostate artery embolization (PAE) as a prognostic factor of success.Thirty-nine patients with PAE were prospectively included. They all underwent pre- and post-PAE trans-abdominal prostate CEUS. Two readers independently evaluated the pre- and post-PAE unenhanced area using a semiquantitative method: unenhanced areas were measured on 3 different slices (basis, middle, and apex) and reported to the whole prostate area. The mean of the three measures was reported semiquantitatively in classes of ten percent and quartiles. We evaluated correlation with clinical success, at 3 months after PAE, defined as a 25% reduction in the International Prostatic Symptoms Score and a Quality of life 3.Twenty-three patients who had bilateral PAE were analyzed. Pre-PAE trans-abdominal prostate CEUS showed visible early and marked enhancement of the entire prostate in all patients. After PAE, all patients had a semiquantitatively measured unenhanced area 25%. The semiquantitative measurement was found to be highly reproducible, with an interclass correlation 0.8. No correlation was found between the area of unenhanced tissue and clinical success evaluated at 3 months.Trans-abdominal prostate CEUS performed early after PAE provides reproducible results and is a valuable tool to evaluate unenhanced areas of the prostate.3, local non random sample.

Background Data about acute poisoning in Italian pediatric patients are obsolete or absent. This study would partially fill this exiting gap and compare the scene with others around the world. Methods A retrospective evaluation was performed on a 2012–2017 data registry of the Children’s Emergency Department at the Regina Margherita Hospital of Turin, where 1030 children under age 14 were accepted with a diagnosis of acute intoxication. Results The median age of the patients was 2.2 years (IQR 2.3) and 55% were male. Events occurred mostly in children aged 1–4 years (n = 751, 72.9%). Six hundred and eight patients (59%) were exposed to Nonpharmaceutical agents, the household cleaning products being the more frequent (n = 298, 49%). Exposure to Pharmaceuticals were 422 (41%); the most common Pharmaceuticals were analgesics (n = 88, 20.8%), psychotropics (n = 77, 18.2%) and cardiovascular (n = 53, 12.6%) drugs. The 85% of the intoxications occurred accidentally, the 10.6% as therapeutic error, the 2.3% as suicide attempts and the 1.5% for recreational purposes. No patient died. Conclusions Despite acute poisoning being a relevant problem in pediatric emergency, our results would seem to paint a less worrying picture if compared to other countries, mainly when considering the children hospitalized in the pediatric intensive care unit and the number of deaths. Nevertheless, our study might represent a tool for public health authorities to program incisive interventions.

Resume Le terme « recherche clinique » designe toute recherche menee sur l’homme en vue du developpement des connaissances biologiques ou medicales. Applicable depuis novembre 2016, la loi Jarde a redefini les contours de la recherche clinique en France. Le changement le plus notable est qu’on ne parle plus de recherche biomedicale mais de « recherche impliquant la personne humaine ». Ainsi, toutes les recherches doivent etre autorisees par un comite de protection des personnes (CPP) avant de pouvoir debuter ; cela inclut aussi les recherches observationnelles telles que les cohortes retrospectives. Autre nouveaute, le CPP est attribue de maniere aleatoire, sur un site internet dedie. Seules les recherches sur donnees (obtenues dans le cadre strict du soin) font exception parce qu’elles n’impliquent pas la personne humaine ; il s’agit en general des donnees extraites de l’entrepot de donnees ou du dossier patient informatise. L’objectif de cet article est d’aider les radiologues interventionnels a comprendre et a optimiser leurs activites de recherche clinique dans le respect du cadre legal nouvellement defini.

To report our initial experience of fully percutaneous deep venous arterialization (pDVA) for the treatment of chronic critical limb ischemia (cCLI) after failed distal angioplasty.pDVA was performed in five consecutive patients by creating an arteriovenous fistula (AVF) between a below the knee artery and its satellite deep vein. In this early experience, only patients with failed prior interventional attempts at establishing flow with no distal targets for an arterial bypass were selected. Early technical success was defined as successful AVF creation and retrograde venous perfusion of the wound site. Patient demographics, procedural details, morbidity/mortality and wound healing outcomes were assessed prospectively. Patients were followed up in wound care centers, and graft patency was documented on duplex ultrasound.All five consecutive patients (mean age 58 years) underwent successful pDVA without any procedural complications. There were neither 30-day major adverse limb events nor major cardiovascular complications. Three out of the five patients (60%) had clinical improvement as observed by resolution of rest pain and complete wound healing. At the 1-month FU, one patient died and one patient received a major amputation. The median wound healing time was 39 weeks.pDVA is a safe and feasible vascularization alternative in patients with end-stage/no-option CLI. The early experience highlights the need for a multidisciplinary approach including a dedicated wound care service.

Objectifs Evaluer le traitement endovasculaire du syndrome post-thrombotique (SPT) lie a une occlusion veineuse chronique iliofemorale ou cave inferieure et determiner les facteurs influencant la permeabilite prothetique. Methodes Dans cette etude multicentrique retrospective realisee dans 15 centres francais specialises en radiologie interventionnelle vasculaire, tous les dossiers des patients traites par stenting endovasculaire pour un SPT lie a une occlusion veineuse chronique proximale entre 2009 et 2019 ont ete retrospectivement analyses. Les taux de permeabilite primaire, primaire assistee et secondaire etaient determines par echographie-Doppler et/ou phleboscanner. L’efficacite clinique etait evaluee grâce aux scores de Villalta et CIVIQ-20. Les resultats du traitement endovasculaire etaient compares a la severite preoperatoire des lesions, a l’extension distale du stenting, a la presence d’une thrombophilie, aux antecedents de recidive thrombotique et au delai avant traitement. Resultats Au total, 698 patients (419 femmes) ont ete inclus. Un succes technique immediat a ete obtenu chez 668/698 (95,7 %) patients, avec un taux de morbidite de 3,9 %. Apres un suivi moyen de 20,7 mois, une permeabilite primaire, primaire assistee ou secondaire a ete obtenue respectivement chez 537/668 (80,4 %) patients, 566/668 (84,7 %) patients et 616/668 (92,2 %) patients. Pour les patients presentant des lesions post-thrombotiques absentes ou minimes, les taux de permeabilite secondaires en fin de suivi etaient respectivement de 96,0 % (216/225) et 92,9 % (131/141), chutant a 88,4 % (168/190) pour les patients avec lesions severes et a 78,9 % (30/38) pour ceux avec des lesions majeures (p = 0,0008). Il n’y avait pas de correlation entre la permeabilite veineuse et l’extension distale du stenting, la presence d’une thrombophilie, l’antecedent de recidive thrombotique ou le delai avant traitement. Les ameliorations moyennes des scores de Villalta et CIVIQ-20 etaient respectivement de 7,0 ± 4,7 points (p Conclusion Le traitement par recanalisation puis stenting endovasculaire peut etre propose dans le traitement du SPT lie a une occlusion veineuse chronique proximale, permettant des taux eleves de permeabilite et d’amelioration clinique a moyen terme, pour un taux de morbidite faible. La permeabilite veineuse apparait par ailleurs fortement correlee a la severite des lesions post-thrombotiques des veines de la cuisse.

Background and aim β 2 -Adrenoceptors (β 2 -ARs) are G protein-coupled receptors (GPCRs) expressed in the major insulin target tissues. The interplay between β 2 -AR and insulin pathways is involved in the maintenance of glucose homeostasis. The aim of this study was to explore the consequences of β 2 -ARs deletion on insulin sensitivity and insulin signaling cascade in metabolically active tissues. Methods and results We evaluated glucose homeostasis in skeletal muscle and liver of β 2 -AR-null mice (β 2 -AR −/− ) by performing in vivo (glucose tolerance test and insulin tolerance test) and ex vivo (glucose uptake and glycogen determination) experiments. β 2 -AR gene deletion is associated with hepatic insulin resistance and preserved skeletal muscle insulin sensitivity. Importantly, we demonstrate that hepatic β 2 -AR regulates insulin-induced AKT activation via Grb2-mediated SRC recruitment through a G i -independent mechanism. Conclusions β-AR stimulation contributes to the development of early stages of insulin resistance progression in the liver. Our findings indicate that the cross-talk between β 2 -AR and insulin signaling represents a fundamental target towards the development of novel therapeutic approaches to treat type 2 diabetes and metabolic syndrome.

Resume Introduction L’occlusion de la veine femorale commune (OVFC) d’origine iatrogene, secondaire a la pose de catheters femoraux ou a des interventions au niveau du Scarpa, est une cause rare mais tres symptomatique d’insuffisance veineuse chronique. Ces patients, insuffisamment soulages par la compression veineuse elastique, sont des candidats pertinents a une procedure endovasculaire de recanalisation veineuse. Methodes Nous rapportons une serie de trois cas d’OVFC developpee a la suite d’interventions au niveau du Scarpa, leur procedure de recanalisation, le controle par echo-Doppler et le suivi a court terme. Resultats Dans chacun des cas, la recanalisation endovasculaire a necessite du materiel rigide (guide rigide ou aiguille de Colapinto) afin de traverser les adherences fibreuses avant de realiser une angioplastie avec pose de stent. Ces procedures complexes ont permis une recanalisation efficace immediate, sans complication majeure. Le controle par echo-Doppler confirmait la permeabilite de la veine femorale commune. Lors de la consultation de controle, les patients ont constate une amelioration rapide et significative de leurs symptomes. Conclusion Chez les patients souffrant d’insuffisance veineuse chronique severe par OVFC d’origine iatrogene, une recanalisation endovasculaire peut etre proposee. Bien qu’il s’agisse de procedures complexes en raison de la fibrose etendue au niveau du Scarpa et necessitant du materiel specialise, aucune complication majeure n’a ete constatee.

Background Post thrombotic syndrome is a frequent complication of deep venous thrombosis, associated with high morbidity. Treatments currently available are invasive. Pulsed cavitational ultrasound therapy (PCUT) is a new technique to destroy remotely soft tissue. We demonstrated that PCUT was able to recanalize non-invasively in in-vitro model of human blood clot. Purpose We aim to test the safety and efficacy of venous recanalization by non-invasive PCUT in vivo swine model of acute venous thrombosis. Methods All the experiments were performed on White large X Landrace swine. We induced an acute femoral deep venous thrombosis by using endovascular approach combined with local injection of thrombin. A 3 cm length occlusive thrombosis was obtained after 2 hours. Swine were divided in three groups: one with PCUT without follow-up (n = 11), one with PCUT and follow-up at 14 days (n = 8), and a control group also followed for 14 days (n = 5). Acutely and during follow up all swine received curative anticoagulation. To achieve PCUT, a 2.25 MHz transducer (Imasonic©) centered by a linear probe was used and cavitation was obtained in the centre of the vein. Effectiveness of recanalization was evaluated by echo-Doppler and phlebography. Safety was assessed by Doppler ultrasound and by histological analysis of vein, artery and lungs. Results Among the 24 swine, we obtained 22 occlusive venous thromboses and 2 partials. The median length of the thrombus was 26 ± 4.4 mm. Acutely, thrombosis recanalization was obtained among the 19 swine with PCUT with median treatment duration of 33 min. After a 14-day follow-up, 75% of recanalisation remains permeable vs. 0% of vein permeable in the no therapy group (P = 0.008). Residual diameter was 2.6 ± 1.2 mm, 50% of the venous diameter. No embolism or pulmonary infarction was observed in all pigs ( Fig. 1 ). Conclusion We have demonstrated in vivo the safety and the efficacy of PCUT for non-invasive venous recanalization, persistent after 2 weeks.

To compare safety and clinical outcomes of embolization of the superior rectal arteries in patients with hemorrhoidal bleeding using particles and coils versus coils only. We retrospectively reviewed data for patients undergoing embolization for chronic hemorrhoidal bleeding from January 2014 to April 2017. Embolization was performed with coils alone or with particles and coils. Clinical scores (Paris bleeding severity score, Goligher classification and quality of life score) were obtained, and embolization was performed with microparticles (300–500 μm) followed by fibered pushable coils. Clinical success was defined as an improvement of > 2 points in the Paris bleeding severity score, without complications. Outcomes were compared between the two groups in a matched-pairs analysis (1:1 scenario), with patients embolized with particles and coils as the study group and patients embolized with coils alone as the control. We treated 45 consecutive patients. After matched-pairs analysis, the final study population was 38 patients (19 study group and 19 controls). Clinical success did not differ significantly between the two populations: 63% for control group and 68% for the study group (p = 0.790). The median change in clinical score was − 3 [− 6; − 1] for the control group and − 3 [− 4; − 1] for the study group (p = 0.187). Grade 1 complications were reported in 15% of patients, with no major complications. Embolization was feasible, with a technical success of 100% and no major complications. Clinical success was obtained in 66% in patients with no difference when using combined embolization with particles and coils versus coils only.

Background Post thrombotic syndrome is a frequent complication of deep venous thrombosis and is associated with high morbidity and hospitalization. Treatments currently available are invasive, involve use of endovenous procedures with stents and balloons, and frequently require general anesthesia. Pulsed cavitational ultrasound therapy (PCUT) emerged recently as a new technique to destroy remotely soft tissue. We recently demonstrated that PCUT was able to recanalize non-invasively in in vitro model of acute venous thrombosis (human blood clot). Purpose We aim to test the safety and efficacy of venous recanalization by noninvasive PCUT in vivo swine model of acute venous thrombosis. Methods All the experiments were performed on White large X Landrace swine. We induced an acute femoral deep venous thrombosis by using occlusive balloons introduced from jugular and popliteal vein combined with local injection of 50 IU of human thrombin. A 3 cm length occlusive thrombosis was obtained after 2 hours. Swines were divided in three groups: one with PCUT without follow-up (n=11), one with PCUT and follow-up at 14 days (n=8), and a control group also followed for 14 days (n=5). Acutely and during the follow up all swines received curative anticoagulation. To achieve PCUT, a 2.25 MHz transducer centered by a linear probe was used and cavitation was obtained in the center of the vein (Figure). After manual determination of thrombus location, a robotic arm was used to automatically move the transducer along the thrombus. Effectiveness of recanalization was evaluated by echo-Doppler and phlebography. Safety was assessed by Doppler ultrasound of the insonified area (artery, veins and surrounding tissue) and by histological analysis (local femoral vein and artery and lungs for pulmonary embolism). Results Among the 24 swines, we obtained 22 occlusive venous thromboses and 2 partial. The median length of the thrombus was 26±4.4 mm with vein diameter of 8.5±1.6 mm. Acutely, thrombosis recanalization was systematically obtained among the 19 swine with PCUT with median treatment duration of 33 minutes with residual diameter of 2.9±0.9 mm. No extravasation of contrast material or hematoma was observed after the therapy. After a 14-day follow-up, 75% of recanalisation remain permeable vs. 0% of vein permeable in the no therapy group (p=0.008). Residual diameter was 2.6±1.2 mm, which correspond to 50% of the venous diameter. No vein or artery damage and no embolism or pulmonary infarction was observed in all pigs. Figure 1 Conclusion We have demonstrated in vivo the safety and the efficacy of PCUT for non-invasive venous recanalization, persistent after 2 weeks. Acknowledgement/Funding French society of cardiology

Background: Carbohydrates play a major role in cell signaling in many biological processes. We have developed a set of glycomimetic drugs that mimic the structure of carbohydrates and represent a novel source of therapeutics for endothelial dysfunction, a key initiating factor in cardiovascular complications. Purpose: Our objective was to determine the protective effects of small molecule glycomimetics against free fatty acid­induced endothelial dysfunction, focusing on nitric oxide (NO) and oxidative stress pathways. Methods: Four glycomimetics were synthesized by the stepwise transformation of 2,5­dihydroxybenzoic acid to a range of 2,5­substituted benzoic acid derivatives, incorporating the key sulfate groups to mimic the interactions of heparan sulfate. Endothelial function was assessed using acetylcholine­induced, endotheliumdependent relaxation in mouse thoracic aortic rings using wire myography. Human umbilical vein endothelial cell (HUVEC) behavior was evaluated in the presence or absence of the free fatty acid, palmitate, with or without glycomimetics (1µM). DAF­2 and H2DCF­DA assays were used to determine nitric oxide (NO) and reactive oxygen species (ROS) production, respectively. Lipid peroxidation colorimetric and antioxidant enzyme activity assays were also carried out. RT­PCR and western blotting were utilized to measure Akt, eNOS, Nrf­2, NQO­1 and HO­1 expression. Results: Ex vivo endothelium­dependent relaxation was significantly improved by the glycomimetics under palmitate­induced oxidative stress. In vitro studies showed that the glycomimetics protected HUVECs against the palmitate­induced oxidative stress and enhanced NO production. We demonstrate that the protective effects of pre­incubation with glycomimetics occurred via upregulation of Akt/eNOS signaling, activation of the Nrf2/ARE pathway, and suppression of ROS­induced lipid peroxidation. Conclusion: We have developed a novel set of small molecule glycomimetics that protect against free fatty acidinduced endothelial dysfunction and thus, represent a new category of therapeutic drugs to target endothelial damage, the first line of defense against cardiovascular disease.

Aortitis is an inflammation of the aortic wall with an infectious or non-infectious origin, which often progresses to vascular complications. The open surgical approach is a high-risk procedure for these pathologies. Endovascular interventions have improved the prognosis of patients with aortitis complications. This manuscript describes the pathophysiology responsible for vascular complications and the role of endovascular approach for their treatment.

The fifth author's name was incorrectly published as "M. Messas". The correct name is "E. Messas". The original article has been corrected.

Objectives Histotripsy has been shown promising for non-invasive treatment of deep venous thrombosis. Important challenges remain, however, to perform a safe and accurate treatment in human patients. The objective of this work was to evaluate 1) the feasibility of this approach assisted by a robot to recanalize effectively a venous thrombosis in vivo and 2) the safety or our device on venous wall injury and risk of pulmonary embolism. Methods A femoral venous thrombosis of 9 pigs weighing 49.6 kg was systematically created. To obtain occlusive thrombosis, we used a double jugular and femoral approach to position the balloons. A thrombosis was obtained after 2 h of stasis associated with 50 IU of human thrombin. A 2.25 MHz transducer (Imasonic©) centered by a linear probe (SL10-2, SuperSonic Imagine©) was used and cavitation was obtained in the center the vein. After manual determination of the thrombus, a 6-axis robotic arm was used to automatically move the transducer along the thrombus trajectory. Success of recanalization was evaluated by the flow restoration, evaluated with phlebography and colour-Doppler imaging ( Fig. 1 ). The safety was assessed by local hematoma research with ultrasound imaging and histological analysis of the lungs for embolism. Results 7 occlusive and 2 subocclusive venous thrombosis were obtained with a mean length of 2.8 ± 0.4 cm. Among them, only 7 were accessible for recanalization because 2 thromboses were too deep (>3 cm). Recanalization was systematically obtained among the 6 occlusive cases, with improvement of flow in the case of partial thrombosis. No extravasation of contrast product or hematoma was observed with radioscopy and ultrasound imaging. The pulmonary arterial tree wasmacroscopically free from embolism. Conclusion Thrombotripsy performed at high frequency (2.25 MHz) is an effective and safe tool to enable non-invasive and thrombolytic venous recanalization.

To compare outcomes of percutaneous robot-assisted uterine fibroid embolization (UFE) using two different endovascular robotic catheters. Twenty-one patients with a symptomatic uterine fibroid were prospectively enrolled in a single-center study to be treated with a percutaneous robot-assisted embolization using the Magellan system. Fourteen patients were treated using a first generation steerable robotic catheter, version 1.0 (group 1), and seven were treated using the new version 1.1 (group 2). Demographic, pathologic, and procedural variables were recorded. Dose Area Product (DAP) and physician equivalent doses were registered for each procedure. Procedural related complications and clinical midterm outcomes were also evaluated. Successful robot-assisted UFE was obtained in eight patients (57.1%) in group 1 and 7 patients (100%) in group 2 (p = 0.01). A successful robot-assisted catheterization of the internal iliac artery anterior branch was performed in all patients of both groups. Median selective target vessel catheterization time was 21.0 ± 12.8 vs 13.4 ± 7 min (p = 0.04) and total fluoroscopy time was 30.3 ± 11.2 vs 19.3 ± 5.9 min, respectively, in group 1 and 2. Mean DAP decreased from 18472.6 ± 15622 to 5469.1 ± 4461.0 cGy·cm2 (p = 0.04). All patients obtained a symptoms relief at 6 months follow-up. Robot-assisted uterine fibroid embolization is safe and effective. New version of steerable robotic catheter allows performing a faster procedure without related adverse events compared to old version.

Aim The aim of this study was to assess the safety and efficacy of the emborrhoid technique (embolization of the superior hemorrhoidal arteries) in patients ineligible for surgery. Materials And Methods Between January 2014 and April 2015, 30 consecutive patients (average age 58 years) suffering from disabling chronic bleeding due to haemorrhoidal disease and with a contraindication for surgery (n= 23) or with a failure of instrumental or surgical treatment (n=7) underwent embolization. All cases were discussed at multidisciplinary meetings including a proctology specialist or a surgeon and an interventional radiologist. We performed super selective micro coil embolization (pushable 2-3 mm fibre coils) of the distal branches of the superior rectal arteries with a microcatheter, via a right femoral approach, under local anaesthesia. We assessed clinical outcome by evaluating bleeding and specific clinical scores relating to bleeding and changes in quality of life. Results Immediate technical success, with no complication, was achieved in 93% of cases. A mean of 3.1 arteries per patient were embolized, with a mean of 7.6 coils per patient. Median follow-up was five months. Clinical score improvement was observed in 72%, in 17 patients after a single embolization session, and in 4 additional patients after a second embolization session. No improvement in bleeding was observed in 8 patients (28%). Conclusion Distal coil embolization of the superior rectal arteries for disabling chronic bleeding due to haemorrhoidal disease is safe and effective in patients untreatable by surgery. This article is protected by copyright. All rights reserved.

Background: p53 is a transcription factor with tumour suppressor properties, which is able to induce mitochondrial apoptosis independently of its transcriptional activity. We recently synthesised two new compounds (ISA27 and SM13), which block p53-MDM2 interaction and induce apoptosis in p53 wild-type (WT) tumour cells. The aim of this study was to verify the effectiveness of these compounds in tumours carrying a mutated form of p53 gene with no transcriptional activity. Methods: In vitro we evaluated the effectiveness of our compounds in cancer cell lines carrying WT, mutated and null p53 gene. In vivo study was performed in Balb/c nude mice and the mitochondrial-dependent apoptotic signalling was evaluated by western blot. Results: Both ISA27 and SM13 reduced cell proliferation and induced apoptosis in vitro in cells carrying either p53 WT or mutated gene, suggesting that its effect is independent from p53 transcriptional activity. On the contrary, SM13 had no effect in a p53 null cell line. In vivo, ISA27 and SM13 induced cancer cell death in a dose-dependent manner through the activation of the mitochondrial-dependent death signalling in p53-mutated cells. In vivo, SM13 reduced tumour growth. Conclusions: Our study proposes SM13 as anticancer compound to use for the treatment of p53-dependent tumours, even in the absence of p53 transcriptional activity.

Objectifs La thrombotripsie a correspond la destruction mecanique d’un thrombus a l’aide d’ultrasons focalises a haute intensite. Cette technologie s’est revelee prometteuse dans des experimentations in vitro et dans une etude sur modele animal. Il reste cependant d’importants defis a relever pour effectuer un traitement sur et precis chez l’homme. A la suite de notre travail in vitro permettant d’effectuer une recanalisation precise et ciblee en reduisant la taille de la tache focale, l’objectif de ce travail etait d’evaluer la faisabilite de cette approche assistee par un robot pour recanaliser efficacement une thrombose veineuse in vivo ainsi que d’evaluer la securite de notre dispositif sur la paroi et le risque d’embolie. Methodes Nous avons cree une thrombose veineuse femorale sur 10 porcs (poids a 49,6 kg en moyenne). Afin d’obtenir une thrombose occlusive, nous avons utilise une double approche jugulaire et femorale pour positionner les ballons. Une thrombose a ete obtenue apres 2 h de stase associee a 50 UI de thrombine humaine. Un transducteur de 2,25 MHz (Imasonic©) centre par une sonde lineaire (SL10-2, SuperSonic Imagine©) a ete utilise et la cavitation a ete obtenue au centre de la veine. Apres la determination manuelle de la localisation du thrombus, un bras robotise a 6 axes a ete utilise pour deplacer automatiquement le transducteur le long du thrombus. L’efficacite de la recanalisation a ete evaluee par la restauration du flux evaluee en Echo-Doppler et par phlebographie. L’innocuite a ete evaluee par la recherche d’hematome de paroi par echo-Doppler et d’embolie pulmonaire par analyse histologique des poumons. Resultats Huit thromboses veineuses occlusives et 2 subocclusives ont ete obtenues avec une longueur moyenne de 2,8 ± 0,4 cm. Parmi elles, seulement 8 etaient accessibles a la recanalisation car 2 thromboses etaient trop profondes (> 3 cm). La recanalisation a ete systematiquement obtenue dans 8 cas, avec amelioration du debit en cas de thrombose partielle. Aucune extravasation de produit de contraste ou d’hematome n’a ete observee. L’arbre arteriel pulmonaire etait macroscopiquement exempt de thrombus. Conclusion La thrombotripsie realisee a haute frequence (2,25 MHz) est un outil efficace et sur pour permettre une recanalisation veineuse non invasive.

βWe evaluated glucose homeostasis in skeletal muscle and liver of ββ-AR stimulation contributes to the development of early stages of insulin resistance progression in the liver. Our findings indicate that the cross-talk between β

Common femoral vein occlusion (CFVO) is frequently found in patients with chronic venous insufficiency. The iatrogenic form, secondary to either central catheter or surgery, is very rare but highly symptomatic. Classical compression therapy barely improves the clinical status of these patients, making them suitable candidates for an interventional procedure for venous recanalization.We report here three consecutive cases of iatrogenic CFVO referred to our outpatient clinic because the disease had an impact on daily life activities. We detail the recanalization procedure, the Doppler control and the short-term outcome.In each case, endovascular recanalization required rigid material (rigid guide or Colapinto needle) to cross the fibrous adhesions before angioplasty could be performed with stenting. The procedure required two attempts in each case, underlining its complexity, but eventually enabled effective recanalization. No major complication occurred per- or post-procedure. One month later, a duplex Doppler control confirmed the permeability of the common femoral vein. The patients had experienced rapid and significant symptom improvement.Patients suffering from severe chronic venous insufficiency caused by iatrogenic CFVO can benefit from endovascular recanalization. Although these procedures may be complex due to the extensive fibrosis at the Scarpa and require specialized equipment, no major complications were observed. Patency of the recanalization persisted at least one month after the procedure. Symptom relief was good.

Ischaemic stroke due to occlusion of large cerebral vessels has a poor prognosis. The clinical outcome is related to efficacy and timing of recanalisation of the occluded arteries. We report our experience with a thrombus aspiration device (Penumbra), and focus on pre- and postprocedural management.We retrospectively reviewed 18 consecutive patients with acute ischaemic stroke due to the occlusion of large cerebral vessels who were treated with mechanical thrombolysis at our centre between September 2009 and July 2010. Preprocedural symptoms were quantified using the National Institutes of Health Stroke Scale (NIHSS). Mechanical thrombolysis was performed with the Penumbra system. Intravenous thrombolysis was done only if3 h had elapsed since symptom onset. Associated vessel stenoses were treated with stenting. All patients underwent neurological examination and postprocedural magnetic resonance angiography (MRA) at 3 and 6 months.Mechanical thrombolysis using the Penumbra system was performed in all cases. A total of 83% of treated vessels had a value of 2/3 according to the Thrombolysis in Cerebral Infarction (TICI) scale. In seven patients (39%) intravenous thrombolysis was unsuccessful, and salvage mechanical thrombolysis followed. Three patients died after the procedure (16.7%). Five patients (27.8%) required a stenting procedure. All patients reported a significant improvement in symptoms (mean baseline NIHSS 19.6±5.6; mean postprocedural NIHSS, 7.8±5.5 p0.0001)Our preliminary experience with the Penumbra mechanical thrombolysis system confirms previously reported results showing the efficacy and safety of the device in treating acute stroke caused by the occlusion of large intracranial vessels.

This study aimed to evaluate the prevalence of chronic cerebrospinal venous insufficiency (CCSVI) in patients with multiple sclerosis (MS).From November 2009 to February 2010, 74 participants (40 MS patients and 34 healthy controls) were enrolled in a randomised singleblind prospective study. All participants underwent ultrasonography (US) to detect signs of CCSVI.CCSVI was detected in 55% of patients in the MS group and 35% in the control group; the difference was not statistically significant (p=0.089).In our experience, a slight difference exists in the prevalence of CCSVI between MS and healthy controls, but it is not as yet clear which parameters may be most significant. This preliminary study failed to show a statistically significant difference in the prevalence of CCSVI among patients affected by MS. It did, however, reveal a tendency that requires a larger number of patients to achieve statistically significant results.

Aortitis is an inflammation of the aortic wall with an infectious or non-infectious origin, which often progresses to vascular complications. The open surgical approach is a high-risk procedure for these pathologies. Endovascular interventions have improved the prognosis of patients with aortitis complications. This manuscript describes the pathophysiology responsible for vascular complications and the role of endovascular approach for their treatment.

Background The DENERHTN trial confirmed the daytime ambulatory systolic blood pressure (dASPB) lowering efficacy of renal denervation (RDN) added to a standardized stepped-care antihypertensive treatment (SSAHT) for resistant hypertension at 6 months. This post-hoc analysis assessed the impact of abdominal aortic calcifications (AAC) on the hemodynamic and renal response to RDN at 6 months. Methods A total of 106 patients with resistant hypertension were randomly assigned to RDN + SSAHT, or the same SSAHT alone (control group). Total AAC volume was measured from the aortic hiatus to the iliac bifurcation, blind to randomization, with semiautomatic software, on the pre-randomization non-contrast abdominal CT-scans of 90 patients and expressed as tertiles. Results The baseline-adjusted difference in the change in dASBP from baseline to 6 months between the RDN and control groups was −10.1 mmHg (P = 0.0462) in the lowest tertile of AAC volume and −2.5 mmHg (P = 0.4987) in the two highest tertiles of AAC volume. Estimated glomerular filtration rate (eGFR) remained stable at 6 months in the patients with the lowest tertile of AAC volume who underwent RDN (+2.5 mL/min/1.73 m2) but decreased in the control group (−8.0 mL/min/1.73 m2, P= 0.0148). In the two highest tertiles of AAC volume, eGFR decreased similarly in the RDN and the control groups (P = 0.2640). Conclusion RDN plus SSAHT resulted in a larger decrease in dASBP than SSAHT alone in patients with a lower AAC burden than in those with a higher AAC burden. This larger decrease in dASBP was not associated with a decrease in eGFR.

Endovascular and subintimal approaches fails in obtaining a below-the-knee recanalization in 10-40% of cases, even in high-volume and expertise centers. The presence of long calcified occlusions, characterized by a complex anatomy, often necessitate the use of alternative techniques in order to obtain a direct blood flow to the foot arteries. Recanalization using pedal and plantar loop angioplasty could improve outcomes in the presence of a communication between the dorsal and plantar arch of the foot, if conventional techniques are not effective.

Diabetes mellitus is an independent risk factor for peripheral artery disease. Life expectancy is 41 months for diabetic patients with an ischemic ulcer. The characteristics of diabetic arteriopathy make its treatment more difficult than in non-diabetic patients. Few data are available about the surgical treatment of arteriopathy in diabetic patients (including angioplasty or bypass), especially in case of distal arteriopathy. The choice of the procedure depends on multiple factors such as the disease localization, its extent, distal blood flow and vascular disease-related surgical risk. The principal aim of revascularisation is to restore direct flow to the foot in order to ensure wound healing and limb salvage. With percutaneous endoluminal angioplasty, limb salvage can be achieved in more than 80% of patients at 1-3 years. The percutaneous procedure is less invasive than open surgery, there are fewer complications, and morbidity and mortality rates are reduced; moreover, a second procedure remains possible in the future. With bypass surgery, the rate of limb salvage exceeds 80% at five years. Nevertheless, peri-operative mortality reaches 3% and arterial anatomy, patient-related risks factors or venous graft availability may be limitations. New endovascular techniques especially designed for the distal arteries of the lower limbs enable very distal revascularization with morbidity and mortality rates lower than with surgery.

Heart Failure (HF) is a complex disease characterized by progressive cardiac dilation and loss of ATP content needed to accomplish myocardial contractile function. GRK2 is a serine/threonine kinase that phosphorylates and binds receptors coupled to G proteins, such as β-adrenergic receptors (βAR) and it is involved in the pathophysiology of HF since its increased levels are associated with the unfavorable development of such disease. Here we tested the therapeutic effects of a small peptide, whose has demonstrated the ability to inhibit GRK2 activity in vitro, on animal model of HF. For this study, 8 weeks old C57BL/6 mice were used and myocardial infarction (MI) of left ventricle was induced by means of a cryogen probe. Cardiac volume and function was assessed by Echocardiography pre- surgery and at 4, 6, 8 and 10 weeks post MI, followed by terminal hemodynamic evaluation by catheterization with Millar pressure transducer. Also, 6 weeks after MI, mice were implanted with a micro osmotic pump set to deliver 0.24 mg/day of grk2 inhibitor for 2 weeks. Finally, mice were sacrificed and heart samples collected for β binding, cAMP and ATP assays. MI induced a significant increase in left ventricle diastolic dimension (LVDD) and reduction of Ejection Fraction (EF) respect to control (LVDD: 4.27 ± 0.23 vs 3.7±0.09 mm, EF : 35.9 ± 0.02 vs 57 ± 3.4 %, MI vs control) at 6 week post surgery. At 8 weeks post MI, treated group showed a significant amelioration of cardiac function (EF: 51.7 ± 4 vs 30.81 ± 1.68, MI+pump vs MI) and attenuation of cardiac remodeling respect to MI control group (LVDD: 3.96 ± 0.11 vs 4.9 ± 0.1 mm , MI+pump vs MI).These results were still effective at 10 week post MI, while hemodynamic evaluation showed a significant amelioration in left ventricle diastolic pressure ( LVDp :1±2.5 vs 14.3 ± 1 mmHg in MI treated respect to MI Control group) and contractility after isoproterenol intravenous infusion (Δ to basal: 4544±320 vs+3197±205, MI+pump vs MI) indicating an improved emptying and a preserved contractile reserve of left ventricle induced by treatment. GRK2 inhibitor treatment restored βAR density (55±1.02 vs 40±1.43 fmol/mg, MI+pump vs MI) and cAMP production (15.9±0.53 vs 8.59±0.85 pmol/mg, MI+pump vs MI). Moreover, ATP content was increased in the heart samples from the treated group respect to post-MI HF not treated group (19450±3259 vs 11036±1896, Fluorescence intensity). These results demonstrate that a small peptide inhibitor of GRK2 is an effective therapeutic strategy to recover functional, biochemical and energetic cardiac properties during HF.

The inversion technique is used in DC soundings intepretation to determine thethicknesses and the true resistivities of the layers, starting from the field apparentresistivities.The relationship between the predicted apparent resistivities and the earthparameters is not linear. Starting from this relationship a methodology is describedto obtain a wellposed system of M linear equations. This system permits tocalculate, by means of an iterative procedure, the earth parameters that minimizethe differencies (error) between the field and the predicted apparent resistivities.Three different iterative procedures are described. Practical examples haveshown that all the iterative procedures are reliable and give comparable results interms of minimum error reached and CPU time.

Diabetes mellitus is an independent risk factor for peripheral artery disease. Life expectancy is 41 months for diabetic patients with an ischemic ulcer. The characteristics of diabetic arteriopathy make its treatment more difficult than in non-diabetic patients. Few data are available about the surgical treatment of arteriopathy in diabetic patients (including angioplasty or bypass), especially in case of distal arteriopathy. The choice of the procedure depends on multiple factors such as the disease localization, its extent, distal blood flow and vascular disease-related surgical risk. The principal aim of revascularisation is to restore direct flow to the foot in order to ensure wound healing and limb salvage. With percutaneous endoluminal angioplasty, limb salvage can be achieved in more than 80% of patients at 1-3 years. The percutaneous procedure is less invasive than open surgery, there are fewer complications, and morbidity and mortality rates are reduced; moreover, a second procedure remains possible in the future. With bypass surgery, the rate of limb salvage exceeds 80% at five years. Nevertheless, peri-operative mortality reaches 3% and arterial anatomy, patient-related risks factors or venous graft availability may be limitations. New endovascular techniques especially designed for the distal arteries of the lower limbs enable very distal revascularization with morbidity and mortality rates lower than with surgery.

Purpose Periprocedural acute distal embolization is a complication that occurs during percutaneous revascularization of the femoro-popliteal and below-the-knee arteries. To date, limited research has been done and no standard of treatment has been established. Material and Methods Three cases using mechanical thrombo-aspiration to treat distal embolization complications from limb salvage treatment are reported. Each case was treated using a novel mechanical thrombectomy device, the Penumbra System (Penumbra Inc., Alameda, California), traditionally used during acute ischemic stroke therapy. It involves a trackable catheter connected to a dedicated aspiration pump (Penumbra MAX Pump, Penumbra, Inc.). In addition, the Penumbra Separator wire technology was available to help prevent the catheter tip from clogging for the duration of the thrombectomy procedure. Thromboemboli and debris extracted from the body was collected from the suction, and could be drained for visual confirmation and further clot analyses at the end of the procedure. Results Of the 3 cases, pre-procedural angiography showed indications of proximal steno-obstructions in the tibial artery in 2 and obstruction of the proximal third of the superficial femoro-popliteal artery in the other. After percutaneous transluminal angioplasty with a balloon catheter was performed, post angiography imaging revealed distal embolization caused by the angioplasty procedure. Mechanical thromboaspiration was used with Penumbra System (3MAX was used in 2 cases, and 4MAX in 1 case) connected to the aspiration pump. Final angiographic imaging showed complete recanalization and occluded arteries were restored to normal flow. A healing ulcer was observed at the 4- to 6-month follow-up, and all 3 patients were asymptomatic at the 12-month follow-up. Conclusions Our initial experience using the Penumbra System in the peripheral vasculature demonstrates a rapid and effective approach to address intra-procedural distal embolization and avoid possible grave clinical sequelae. Follow up in a larger cohort is warranted with this system.